Institutionalizing Psychoanalysis

I will assume that the title of this article raises as many hackles as plaudits from our members. Much of the history of psychoanalysis has been the point-counterpoint debate between those who have attempted to make psychoanalytic theory and practice conform to the “normal” development of a medical specialty or scientific discipline and those who see psychoanalysis as sui generis, a humanistic endeavor that can only thrive if unshackled by regulation and prescription. The debate has been exacerbated by the fact that its founder can readily be enlisted on one side or the other. And you may have noticed that yoking together psychoanalysis as both specialty and discipline will also raise howls of protest from those who see the other approach as stifling the progress of psychoanalysis. For my purpose, however, I want to make the case that our Division’s efforts to support “institutionalizing psychoanalysis” serve a vital mission to support psychoanalytic psychology. Not only has the Division made an enduring commitment to this task over the years, but also we have spent handsomely to maintain that commitment. Your membership dues at work!

If you have been reading my columns over the last year, you are aware that our major psychoanalytic organizations, the American Psychoanalytic Association (APsaA), the American Academy for Dynamic Psychiatry and Psychotherapy (AAPDP), the American Association for Psychoanalytic Clinical Social Work (AAPCSW) and the Division formed a loose organization, the Psychoanalytic Consortium, over twenty years ago for the purpose of working on common interests in psychoanalytic practice, teaching, training, and research. During these years, the major work of the Consortium has been to develop a common set of standards that can be applied in any program of advanced specialization in psychoanalysis. During the first ten years, the Division did the lion’s share of the work in forging a consensus that eventually led to the development of the Accreditation Council for Psychoanalytic Education (ACPE).

The ACPE is a wholly separate organization that was established to implement the training standards developed by the Consortium and specifically to become an accrediting agency that would be able to review and approve a wide array of training programs that met the criteria outlined in the standards document. In order for this external accrediting agency to have perceived value for training programs, ACPE must eventually seek and obtain the approval of the Department of Education (DoE) to serve in this capacity.

How does this “institutionalize psychoanalysis?” If ACPE succeeds in becoming both recognized by the DoE and increasingly utilized by diverse training programs, psychoanalysts will be able to say to potential patients, colleagues, policy makers, and the public at large that psychoanalytic training is a recognized, accredited specialty of the mental health disciplines with a common set of standards that are open and transparent for review. Will it get us more money, more patients, more respect from colleagues and the public? Perhaps not. But psychoanalysis will inarguably become a recognized specialty for treatment of mental illness and emotional problems.

The Psychoanalytic Consortium was able to launch ACPE and to provide the seed money for it to get started. ACPE has in turn been active in enlisting institutes to apply for accreditation and in the process work out some of the inevitable kinks and snafus working with such a diverse constituency, from large and small psychoanalytic training programs all the way up to the mysteries of DoE bureaucracyspeak. The Consortium members are committed to provide seed money through 2012. After that, ACPE will need to become self-funding through accreditation fees. Once that happens, ACPE will finally become a fully autonomous agency and the Consortium will be able to move on to other common projects. More on that in another report.

Staying on the theme of “institutionalizing psychoanalysis,” over the last twenty years our Division leaders have also been instrumental in developing a process to certify that a psychologist meets criteria to be a psychoanalyst. The American Board of Professional Psychology (ABPP) has recognized psychoanalysis as a specialty and the American Board of Psychoanalysis in Psychology has developed rules and procedures to allow psychologists to apply for this certification following completion of psychoanalytic training (or its equivalent). The value of this certification is that it comes from an external organization (ABPP) and is not based on the kind of psychoanalytic training the person has had. The goal that ABPP has had is that all psychologists will routinely apply for an ABPP as part of their postgraduate education, in the hope that this recognition will help the early career psychologist be able to define their specialty before the public and employers.

For many reading this report, the benefits of either accreditation of their institutes (through ACPE) or certification of their psychoanalytic specialty (through ABPP) may seem remote. For many of our members, completing a formal program of psychoanalytic training is no longer a option and this loss, however important, does not interfere with their abiding commitment to psychoanalytic thought, theory, and treatment. For many of our members, applying for one more evidence of skill, one more test of ability, may also seem tedious, pointless, or both.

So it may be difficult to “close the deal” and have your full support for these core commitments of the Division. As individuals, few members of the Division will directly participate or benefit from these initiatives. Even for those that do, it may well be that little personal benefit accrues to the time and expense of seeking an ABPP and that psychoanalytic training will be good or bad regardless of ACPE oversight. It may well be that complying with ACPE requirements or meeting the expectations of an ABPP certification board can only add a burden without offering an advantage. I will concede much of this and more, yet I still want to make the case of the value of these initiatives regardless of how many in the Division actually are personally affected by them.

I propose that ACPE and the ABPP in Psychoanalysis in psychology benefit psychoanalysis as a discipline and psychoanalytic psychology as integral to the science and practice of psychology. The ACPE process, if it succeeds, will mark a major step in allowing our competing psychoanalytic organizations, theories, and diverse histories to find common ground in way undreamt of only twenty years ago. More importantly, in an era where psychoanalysis is routinely dismissed, having recognition from the government, having a common set of standards, is a major step in securing our vision of psychoanalysis as an advance specialization within the mental health disciplines.

Similarly, if we are able to establish the ABPP in Psychoanalysis in Psychology as a certification that is routine among many of our members, we will be able to present a clearer message within APA and to the public at large that our skills and training are worthy of respect and attention. Keep in mind ABPP will accept equivalent training for applicants who are able to demonstrate sufficient training otherwise (and who were otherwise unable to attend an institute due to distance, family obligations etc.).

I hope I have convinced you of the importance of ACPE and the ABPP and that these and other efforts to advance psychoanalysis as a discipline are necessary if not sufficient. Please consider learning more by going to ACPEinc.org (for ACPE) and http://www.abpp.org/i4a/pages/index.cfm?pageid=3360 (for ABPP). While the Division Board has strongly supported these efforts, we continue to seek other ways to advance our discipline within the American Psychological Association and more broadly within the psychoanalytic community. But that is for another report.

President’s Column For November: Executive Committee Meeting

The Executive Committee (EC) of the Division 39 Board consists of the officers of the Division (presidents, secretary, and treasurer) and Division Representatives to APA Council. We meet four times a year, typically the evening before the Division Board of Directors Meeting to clarify the agenda items that will be discussed at the meeting. Once a year, however, we meet separately from the Board, and we met last week to discuss and decide the following issues.

Budget Issues

One of the most important items up for discussion concerned the budget. We are facing a number of “large ticket” items in the coming year and our board and committees will be asked to look very carefully at expenditures. We are actually anticipating an increase in income from member dues, a very rewarding piece of news, since our other source of income (that is, royalties from the electronic version of our journal), while significant, is leveling off. Our other source of income is the profits from the Spring Meeting and that is always a matter of concern, especially in this tight economy. That said, our financial situation is quite stable and under the leadership of Marsha McCary, we have succeeded in building up considerable financial reserves. The Division Board will review and decide on the final shape of our budget in January.

Board and Committee Retreat at the Spring Meeting: April 17-18, 2011

One unusual expense will be for the upcoming retreat. The board members and committee chairs will be meeting a few days prior to the Spring Meeting (April 18-22) to discuss the current issues facing the Division and to help identify priorities for us in the coming years. This will be the first retreat in ten years (also held in Santa Fe). We will be asking our members for their ideas and advice in a more formal way around the beginning of the year, but please let us know your own priorities for the Division by writing me.

Publications

No area of the Division has undergone such a dramatic shift in focus in recent years than our publications. One print publication, Psychoanalytic Abstracts has been reborn as an online publication, PsycScan: Psychoanalysis. The newsletter, Psychologist-Psychoanalyst, has been “retired;” and two new publications, DIVISION/Review and InSight have been launched. Finally, our website has been completely revamped and now is able to make full use of APA’s Internet resources.

Our journal, under Elliot Jurist’s leadership, has become leaner and more oriented to research articles than in the past. This shift has been made partly at the request of the Division leadership, but also as a way to give the journal a higher profile in the publishing world. Without going in to the various ways journal quality is calculated, this new emphasis should help bring the journal up in the rankings of similar journals. As noted above, the journal actually earns money for the Division. APA’s electronic subscription services have rapidly expanded in the last few years both nationally and internationally and the Division shares earning from this service based upon the actual number of journal articles downloaded.

Our new publication this year, DIVISION/Review, has been developed under the editorship of David Lichtenstein who would like the review to become a more general interest psychoanalytic publication that will appeal to a wider public in addition to the Division readership. This shift in focus, however, comes at an increased cost due to a need to improve the production values of the publication to make it more appealing. This is a major undertaking and one that definitely has implications for how the Division seeks to “position” itself within both the psychology and psychoanalytic world.

The monthly online publication, InSight, under Tamara McClintock Greenberg has been more or less established in most members’ minds over the last year as it arrives on our electronic doorsteps on the first of the month. As a publication available to anyone for the price of a request, it too is serving a varied audience and serves as an important reminder and updating service concerning Division activities.

Finally, there is the website, under the editorship of Barry Cohen. In many respects the website is intended to be the main replacement for the old newsletter, in that it has the capacity to highlight breaking news as well as serve as a repository for ongoing reports of our far-flung chapters, sections and committees. We hope to further the development of the site to provide more opportunities for interaction among our members, although we already have a Facebook account that members are free to post. Be sure to “friend” psychoanalysis!

I have focused on the changes in our publications as a way of highlighting our ongoing effort to develop a vision for our Division that meets the diverse needs of our membership. At the same time, our vision is always subject to clarification and reflection. The main goal of our retreat will be to think together about our publications, our meetings, and our outreach and “inreach” efforts to carry out our mission as an organization committed to psychoanalytic psychology.

Council of Representatives

Currently we have seven representatives to APA Council, although we will only have six in the coming year. If members support the Division by giving their ten votes to the Division on their apportionment ballot this month, we will be able to regain our seventh seat. While APA Council meets only twice a year, the work of our council representatives is an ongoing effort to keep abreast of issues of concern to the Division. APA is a vast organization with various boards and committees that play a major role in shaping APA policy. Although APA Council has the final say in the direction of our parent organization, much of the work is always happening “back stage,” including in the various caucuses of Council. Our representatives are active in participating and leading these caucuses, including Divisions for Social Justice (DSJ), Association of Practicing Psychologists (APP) and so on. We are also grateful to our Division members who are serving as liaisons to APA Boards and other areas of APA governance.

Practice Directorate

During our meeting, Katherine Nordal, head of the Practice Directorate and the APA Practice Organization (APAPO) joined us by telephone to discuss the various ways the Division can cooperate with APA and to impress upon the APAPO the importance of protecting patients’ rights to seek psychotherapy including psychoanalytic psychotherapy that is private, secure, and confidential.

The reality is that APA remains highly focused on promoting a vision of psychological care that is based on the concept of “integrated health care” and envisions psychologists working within large healthcare organizations and functioning primarily to direct and evaluate programs rather than perform individual, family or group psychotherapy. While Dr. Nordal expressed her thanks for a list of references documenting the evidence basis for psychoanalytic psychotherapy (compiled by Tamara McClintock Greenberg), it is clear that our view of how to promote emotional growth and change is not a high priority for the APAPO. During the Spring Meeting in New York earlier this year, Ken Levy, in discussing efficacy of psychodynamic psychotherapy, began with the simple but profound statement that long-term change requires long-term work, an observation that applies equally to emotional growth, cigarette cessation, and national infrastructure development. We live in a culture that demands only short-term improvements; and this applies equally to managed care, Wall Street, and our political system. The ability of our members to hold open a space for long-term emotional change (change that continues long after psychotherapy ends) will remain largely our task. We are likely to find allies within other Divisions and members of APA, but it is a struggle that this Division must uniquely bear.

Depressive Disorders Treatment Guideline Development Panel: During our discussion with Dr. Nordal we emphasized again the need for a psychodynamic perspective on the new panel that will be formed to develop guidelines for the treatment of depression. Two members of our Division have placed their names “in the ring” (Tamara McClintock Greenberg and Jared DeFife) and we reminded Dr. Nordal that our nominees for the original task force (that outlined the overall direction of this and future task forces) were not selected. The ultimate problem remains that treatment guidelines for specific DSM-IV-defined disorders is conceptually and practically difficult if not absurd. There is, to paraphrase Winnicott, no such thing as a “depressed person.” At best the guidelines represent an attempt to prevent managed care from developing more onerous and absurd guidelines so that everyone can pretend that what we say we do is what we do. The best result is that the guidelines may help us be more successfully duplicitous with a healthcare system that cares not a whit for health or care. All that is lost, then, is a vision of psychotherapy as a humanistic endeavor to help people develop and deepen their emotional life and connection to others.

Division of Psychoanalysis Endorses Petition to DSM-V Committee

Many of you are aware of the revisions being proposed to the Diagnostic and Statistical Manual (DSM) published under the auspices of the American Psychiatric Association. The efforts of the earlier committees that revised the DSM were understandably directed toward developing standard diagnostic criteria for standard diagnostic categories. While a major reason for this development was to be able to bill for psychiatric services, the DSM has served to bring some order to the vast array of competing theories and descriptions of human ills. Perhaps ending up with a plethora of diagnoses for addicts (is a cocaine addict really all that different from the opiate addict he might be in a few years?), for example, is the price paid for increased order.

The new DSM, however, appears to not only suffer the faults of its predecessors, but to increase those errors in ways that are likely to be pernicious. In addition to the vast increase in behaviors now carrying a psychiatric label, the manual will place even greater emphasis upon pathophysiology as etiological (even in the face of an absence of coherent etiological models).

A number of organizations have weighed in against the proposed changes to the DSM including the British Psychological Society and American Counseling Association. The Division of Humanistic Psychology (32) has been circulating a petition calling attention to the problems noted above and others, calling for the DSM-V Committee to take note of these concerns. Division 32 is asking individuals and group to sign a petition supporting these efforts. The petition may be found at www.ipetitions.com.petition/dsm5

The Executive Committee endorsed this petition and I would encourage our members to go to the petition site and review the information for themselves and consider signing on as individuals. As of today, eleven APA Divisions have endorsed this letter.

Division of Psychoanalysis Endorses Effort to have APA Withdraw the PENS Report

As I reported last time, the Coalition for an Ethical Psychology (CEP) has circulated a petition calling upon APA to annul the PENS report. This report, while it no longer represents APA policy is still being cited as a basis for psychologists making ethical decision concerning involvement with illegally held detainees in Guantánamo and other sites. The petition has been widely circulated and signatories include many individuals and groups that are not psychologists as well. It is available at ethicalpsychology.org/pens

The Executive Committee struggled with the issue of endorsing this petition. There was a clear consensus that the PENS report was adopted in haste and error and should certainly not be used to represent or reflect APA policy. The efforts of many of our members to not only oppose the PENS report but to reverse APA and APA Ethics Committee position that psychologists could operate ethically in assisting in interrogation and other interventions is testimony both to the strong stand they took (wholeheartedly supported by the Division Board) and to their tenacious efforts to work within APA governance structure, however cumbersome and time-consuming.

Our concern in discussing the petition was our inability to see the petition as “moving the ball forward” to actually impact APA policy. The petition certainly addresses the ways the PENS report has continued to influence APA decisions and action, in contradiction to the spirit if not the letter of actual APA policy. While the EC ultimately voted to sign the petition, we have also conveyed to the leadership of CEP our wish and expectation that they will work to identify concrete steps to take to bring the issue of the PENS report to APA, specifically, APA Council of Representatives, and to develop the language and procedure that will actually allow the PENS report to finally be withdrawn as a document that has any standing inside or outside APA.

Division of Psychoanalysis Calls for Revision of the Proposed Ethics Casebook

Years ago, the Ethics Committee was charged by APA Council to develop an Ethics Casebook to clarify what psychologists could and could not do when serving in detention centers where detainees were being held illegally. At the time, there were strong reasons to develop a casebook in the face of several factors: 1) APA policy has long endorsed the principles of the Geneva Conventions that psychologists cannot ethically participate in any way in cruel, unusual, and inhuman treatment of detainees; 2) the PENS report outlined possible ways that psychologists could participate in interrogations of illegally held detainees without violating these prohibitions; and 3) the APA Ethics Code allowed an exception to the prohibitions when and if the psychologist was following “valid orders.”

Subsequently APA Council of Representatives endorsed as APA policy the results of a referendum stating that psychologists could not operate ethically in detention settings such as Guantánamo (with certain strictly defined exceptions). It also endorsed a revision of the Ethics Code to eliminate the “valid orders” exception. Despite this the APA Casebook, as currently published for public review, contains reference to the PENS report, suggests that psychologists are able to decide when and if certain actions constitute torture, and so on. The public comment period was initially slated to end a month ago, but due to protests from a number of members the comment period has been extended until February.

The Executive Committee discussed this issue and our concerns that the Casebook should be either scrapped or extensively revised. While a number of our members have written comments along these lines, it is important that others write down their concerns and let APA Ethics Committee hear your opinions.

Division of Psychoanalysis Calls for the Release of Syrian Psychoanalyst, Rafah Nached

There has been a call from a number of psychoanalytic organizations to protest the arrest of Rafah Nached, a Syrian psychoanalyst. The EC voted to sign the petition calling for her release and to communicate this decision to APA leadership, other psychoanalytic organizations and the State Department.

The following information comes from Roger Litten and Betty Bertrand-Godfrey
(Chair and Secretary of The London Society of the New Lacanian School): “I am writing to you concerning the imprisonment of Rafah Nached, a Syrian psychoanalyst who was arrested on 10 September at Damascus airport when she was on her way to see her daughter in Paris. Rafah is 66 and has heart disease for which she needs medication and we have recently received news that her health is deteriorating. She has been imprisoned and placed in solitary confinement by the Syrian authorities for practicing and transmitting psychoanalysis with her fellow countrymen in Syria. Beyond our concern for Rafah herself, we are concerned for what this imprisonment represents for humanity; the principle of psychoanalysis is speech, the freedom of speech, and thus our fight to save Rafah is also a fight to save the freedom of speech as fundamental to psychoanalysis as well as our humanity. We refuse to be silenced.”

If you want to learn more about this petition or to sign the petition, go to http://www.oedipe.org//phpPetitions/index.php?petition=3

Psychoanalytic Psychology and the APA--Part 2

Psychoanalysts in the News

Hedda Bolgar, recent recipient of the Division 39 Leadership Award, has been honored once again, this time for her further contributions late in life with the Outstanding Oldest Worker Award from Washington DC-based organization Experience Counts. Dr. Bolgar remains, at the age of 102, active, engaged and fascinating. Profiled recently in the LATimes, reporter Steve Lopez described her as having a “healthy cynicism and unflagging energy.” She continues to work and teach at the Wright Institute, an organization she co-founded many years ago. I hope she remains a vital presence in the Division for many more years. To read the article, go to www.latimes.com/news/local/la-me-1002-lopez-bolgar-20111002,0,5869414.column

And While We are at It

Belated birthday wishes to Sylvia Brody, who turned a mere 98 years of age this month. Dr. Brody, psychologist, psychoanalyst, and developmental researcher, came to prominence with her books documenting her observational, clinical, and theoretical studies on maternal behavior and child development. Among her contributions were Patterns of Mothering (1950), Anxiety and Ego Formation in Infancy (1970), Mothers, Fathers, and Children: Explorations in the Formation of Character in the First Seven Years (1978) and the follow-up study of the sample at eighteen years, Evolution of Character (1992). In 2002, Dr. Brody published The Development of Anorexia Nervosa; a second edition came out in 2007. Her latest book is Beginning to Grow: Five Studies published by International Psychoanalytic Books.

The DSM-V and the ICD-9

There is continuing controversy concerning the development of the revision of the DSM. The APA has been following these developments, although you should be aware that the DSM is a wholly owned subsidiary of the American Psychiatric Association and it is this organization that will decide how and when the revision is published. At a recent discussion during the APA Convention, Ken Levy noted that the Axis II Diagnoses have aroused some controversy and criticism, although in general he felt there was sufficient recognition of the psychodynamic perspective that we could live with this section.

The leadership of Division 32 (Humanistic Psychology) has recently circulated an initiative requesting Divisions to sign an open letter to the DSM Committee to address the problems that may arise if the revisions go forward. In part the letter reads:

“We are concerned about the lowering of diagnostic thresholds for multiple disorder categories, about the introduction of disorders that may lead to inappropriate medical treatment of vulnerable populations, and about specific proposals that appear to lack empirical grounding. In addition, we question proposed changes to the definition(s) of mental disorder that deemphasize sociocultural variation while placing more emphasis on biological theory.”

Division 32 is asking psychologists and others to sign onto this letter and join the British Psychological Society and the American Counseling Association in raising these concerns. The Practice Directorate and APA Board have been promoting the idea of actually replacing the DSM with the new ICD-9, but it is uncertain what impact this would have as long as the DSM reigns supreme in its original purpose to support psychiatrist reimbursement from insurance companies. To read the petition, go to http://www.ipetitions.com/petition/dsm5/ and decide whether or not to support this campaign.

Corporations and Not People

Psychologists for Social Responsibility (PsySR) is an independent organization composed of psychologists concerned with social justice issues. Although not formally affiliated with APA, it works closely with other APA Divisions. It has sent around a position statement on corporations and would like psychologists to review this document, which begins:

”In recent years, a groundswell of movement in diverse areas has brought critical attention to the notion of corporate personhood, which bestows upon for-profit corporations the same protections afforded to real people. Psychologists for Social Responsibility (PsySR) believes that corporations deserve legal protections, but only as artificial entities—the original designation for corporations, prior to being deemed “persons” by the nation’s courts. PsySR therefore stands alongside the growing number of voices calling for broader action against corporate personhood.”

Go to http://www.psysr.org/corporate-personhood to review the entire document.

On a More Horrific Note

International psychoanalytic organizations and others are trying to raise concerns about a Syrian psychoanalyst, Rafah Nached, currently being held in solitary confinement in a women’s prison in Damascus. Jacques-Alain Miller of the Association Mondiale de Psychanalyse in Paris, established the Free Rafah Nached campaign to call attention to her plight. She appears to have been arrested solely due to her work as a psychoanalyst. The petition (in French, I couldn’t on in English; but it is easy to figure out) is http://www.oedipe.org/phpPetitions/index.php?petition=3

Let’s End on Some Good News

This from Nina Levitt, EdD, Associate Director of the Education Directorate: We want to share some good news with you regarding funding for the Graduate Psychology Education (GPE) Program and the Garrett Lee Smith Memorial Act (GLSMA) Campus Suicide Prevention Program. While work on Fiscal Year 2012 appropriations is far from over in terms of determining the final appropriations levels for these programs and others, positive advancements have been made.

As some of you already know, one of our Champions, Senator Jack Reed (D-RI), pushed very hard on behalf of the GPE Program during this appropriations FY 2012 cycle. Not only was he able to protect the program at its currently funded level ($2.927 million), he also personally requested that very strong Report Language be included in support of the program. More specifically, language was included in the Senate Labor, Health and Human Services, Education and Related Agencies (Labor-HHS) Appropriations Subcommittee report to reinstate the geropsychology component, initiate a focus on veterans and help integrate health service psychology trainees at Federally Qualified Health Centers to provide mental and behavioral health services to underserved populations.

Regarding the GLSMA FY 2012 funding, the Campus Suicide Prevention Program received nearly $5 million in funds from the Senate Labor-HHS Appropriations Subcommittee and, in addition, will receive $10 million from the Prevention and Public Health fund. This, too, was largely the work of Senator Reed. These competitive funds, administered by the Substance Abuse and Mental Health Services Administration, are available to centers on college campuses that provide mental and behavioral health services.

On a related note, Senators Jack Reed, Lisa Murkowski (R-AK), Dick Durbin (D-IL) and Tom Udall (D-NM) introduced a strong reauthorization bill for the Garrett Lee Smith Memorial Act programs (S.740), championing both the authority and the funding for the programs, especially the Campus Suicide Prevention Program. To date, there are a number of additional co-sponsors.

Psychoanalytic Psychology and the APA: Part I

Psychoanalysis has had a curious relationship within American psychology and the APA in particular for over a century. As is well-known, J. B. Watson saw psychoanalytic ideas largely as a challenge to be met and defeated in advancing a strictly behaviorist approach to understanding people; but that is not the whole story. Clark Hull, John Dollard and Neal Miller, among others, viewed psychoanalysis as largely compatible with learning theory and sought to integrate Freudian concepts into their work . B.F. Skinner, and following him the radical behaviorists, were attracted to many aspects of a psychoanalytic approach and reportedly Skinner applied to the Boston Psychoanalytic Institute for training but was turned down.  So much for the spirit of inclusion within American Psychoanalysis!

Despite these important connections (and a review of former presidents also suggests that psychoanalytic psychologists have played a prominent role in the APA), it seems fair to say that psychoanalytic theory, therapy, and research have been consistently marginalized over the years within the APA and American psychology generally, never more so now than before. While many of the criticisms leveled against psychoanalysis have accurately noted the absence of rigorous, controlled studies demonstrating the efficacy of psychoanalytic therapy, this has actually changed quite a lot in recent years and there have been numerous studies and meta-analyses demonstrating that psychoanalytic therapy works, and in many ways works better that other approaches (e.g., more qualitative improvement, more sustained improvement, more emotional growth following completion of treatment, and so on. Despite this, the dismissal of psychoanalytic treatment has continued apace and increasingly reveals the ideological biases within American psychology. See Jonathan Shedler’s article, “Science or Ideology”  for a clear exposition of what psychoanalytic researchers must face. While increasingly demonstrating that psychodynamic researchers can “play the game” and use RCTs and other presumably “gold standard” procedures, Shedler concludes that the ideology of those committed to CBT trumps any fair evaluation of the results obtained.

The animus within the hierarchy of American psychology has been expanded beyond psychoanalytic treatment to encompass all of psychotherapy. Only recently a former president of APA, Alan Kazdin, was quoted in Time disparaging individual psychotherapy as largely unhelpful and psychotherapists as unskilled to deliver “evidence based treatments.”  His comments largely echo the position of the Association for Psychological Science  as well, which has recently proposed taking over the APA’s role in accrediting clinical programs due to the presumed incompetence of psychotherapists currently trained under APA guidelines. I need not comment further on the Kazdin article, since Jared DeFife’s blog in Psychology Today “Is This the End of Individual Psychotherapy?”   covers that ground, except to note that once again the critics of psychotherapy feel no need to provide the evidence basis for their observations.

It will not come as a surprise to you that the APA and the Practice Directorate have been less than helpful in addressing these ongoing and expanded assaults against psychotherapy. Wedded in recent years to the new mantra of “integrated health care,” the idea that individual and family psychotherapy focusing on developing trust and sustained commitment to change within a context of privacy almost certainly cannot be delivered in the hot house of an outpatient clinic. Literally advocates tout that access to psychotherapy will be as easy as sending the patient “down the hall” after being seen by the “real” doctor, scheduled as just another stop along the way to, say, the nutritionist. Efforts to address this fundamental incompatibility of this model (however useful in some contexts, with some patient populations) is simply ignored in favor of this one-size-fits-all approach with the patronizing insistence that we psychotherapists need to catch the “second wave,” forgetting that tsunamis are best dealt with by running as fast as you can in the other direction.

So on this cheery note, I want to emphasize that there are things that you can do. While the Division Board and other leaders in the Division have taken active steps in many ways, it is also up to you as individuals to make your needs and ideas known to APA leadership, to your colleagues, and to the general public. The following are some ways to get active.

Have You Voted for APA President Elect?

Time is running out on the APA President-Elect elections, ending November 1. Please consider the Division Board’s recommendation to endorse Steven Reisner and Doug Haldeman equally. We encourage you to vote for both Haldeman and Reisner, listing them as your first or second choice. Regardless, we need you to vote.

Will You Vote for Division 39 Representation for APA Council on the Upcoming Apportionment Ballot?

On November 1 the APA Apportionment ballots will be sent to all Members and Associates. You are entitled to give ten votes to any Division or SPTA  of your choice. I urge you to give all ten votes to Division 39 to retain our six APA Council seats and perhaps win back our 7th seat that we lost last year. Every vote counts, and for the last three years, only about 1/3rd of our members have given us one or more votes. If every member votes, we will surely retain the largest divisional representation on APA Council.

Division Board Members and other volunteers will be calling every voting member the week of November 1 to remind you to vote; and we hope to be able to talk to you then about the Division and its goals. If not, please send your thoughts and comments to us, either by writing Ruth Helein, our administrator at div39@namgmt.com or me at drmacg@comcast.net

Take Part in a Survey of Experience With Mental Health Parity Law Implementation

APA's Division 42 (Psychologists in Independent Practice) Advocacy Committee is conducting a survey on psychologists' early experiences with the implementation of mental health parity around the country. We would greatly appreciate your informing your constituents and members about the availability of this survey. The deadline for taking the survey is December 4th. The data will be tallied and reported to the Division 42 Board of Directors after which time it will be reported on the Division's website at Division42.org and distributed to other interested parties and entities.

Go to https://www.surveymonkey.com/s/Div42MHParity. Your participation will provide valuable information to assist with our future advocacy activities.

Make Your Views Known on the Ethics Casebook

The Ethics Committee has posted a series of questions to guide psychologists in making ethical decisions when working with detainees. The casebook has been “in the works” for years and was initially based upon the PENS Report that held that psychologists should be able to work ethically in detention settings and to assist in interrogations. Since this policy has been superceded by the referendum passed by APA membership and subsequent action of APA Council, the Casebook questions (and answers) need to be reviewed and revised. Initially, the review process was to be concluded this month, but has been extended into next year, following strong protests from our members and others.

There are many in the Division who find the entire enterprise confounded by the failure of APA to clearly articulate the actual policy psychologists are to follow and see the Casebook as another way to avoid this articulation. Given the actual question and answers in the current Casebook, this view seems warranted in that there are references to the PENS Report as sanctioning psychologist involvement in interrogations and statements that appear to leave it up to the psychologist to determine whether or not detainees are being held illegally and to determine whether or not a particular procedure constitutes torture. These and other comments in the Casebook appear to completely undermine current APA policy in favor of a return to the PENS policy that if a psychologist thinks what he is doing is ethical then it is ethical.

I believe it is a fair assumption that many in APA leadership simply want the controversy over the PENS report and other evidence of APA support for psychologist involvement in interrogations to “go away.” There was palpable relief when APA Council voted to accept the results of the referendum and Laurie Wagner and others who had worked so tirelessly to address the interrogations issue were given a standing ovation. At the same time, there has been little evidence that APA leadership has taken active steps to make clear that we are under a new policy that supplants the PENS report and which stands in direct contradiction in important respects from this report. As members you will have the most impact if you directly address the issues raised by the Ethics Casebook.

Please go to http://www.apa.org/monitor/dec07/ethics.aspx to review the Ethics Casebook and provide your comments. It is vital that members contribute to this process. While written before the Ethics Committee agreed to extend the comment period, go to http://dissenter.firedoglake.com/2011/08/24/apa-casebook-on-psychologist-ethics-and-interrogations-fails-to-convince/ for an excellent review of the issues involved. Please keep in mind that APA is a democratic organization and it takes the weight of numbers and clear opinions to get the attention of APA leaders.

Information Item: A Call for Annulment of the PENS Report

The Coalition for an Ethical Psychology is spearheading a call for annulment of the American Psychological Association’s deeply flawed 2005 Presidential Task Force Report on Psychological Ethics and National Security (PENS). The key conclusion of the PENS Report, despite clear evidence to the contrary, is that psychologists play a critical role in keeping national security detainee interrogations “safe, legal, ethical and effective.” The PENS Report continues to be used as an authoritative document today, especially in national security contexts. Leading human rights groups and professionals from a range of fields, including psychology, medicine, law, military, and intelligence, have therefore joined together in this important annulment effort. A background statement with detailed documentation is available online at www.ethicalpsychology.org/PENS_Annulment_Background_Statement.pdf

Final Comments

While many of our members support this petition, it is also important that we work within APA governance structure on a sustained and continuing basis to address this and other issues of importance to us. The best examples of this are the successful efforts (however mixed the results) that led to the current APA policy that psychologists should not be involved in interrogation of illegally held detainees under any circumstances and the change in the ethics code to make clear that psychologists following valid orders are still obligated to avoid any action that violates basic human rights.

These efforts were certainly championed by members outside the governance structure, but beginning with Neil Altman’s original motion places before APA Council, many Council members worked to keep the issue alive and brought it to the vote alluded to above. Even the referendum was an extremely clever way to work within the governance structure, to find the means within the bylaws to bring about change through direct appeal to the membership.

I hope that I will have more to report on this after our Executive Committee Meeting in November and in particular our efforts to engage other Divisions and other APA Council representatives to address both the flaws in the Ethics Casebook and the continued reliance on the PENS report within the Department of Defense.

To comment on this column or any other aspect of Division 39, please do so on my blog www.chimneysweeping2.blogspot.com

Highlights of the Division Board Meeting

Transitions

The Board of Directors met last week during the APA Annual Convention to discuss, debate, and decide a range of issues facing our organization and psychoanalytic psychology in general. The August Meeting is always a time of transition; and next year’s board will be very different in composition. With the election results in, we will soon be greeting new board members in January, with Frank Summers as President-elect, Lu Steinberg as Treasurer, Norm Abeles, Laura Barbanel, and David Downing as Council Representatives, and Jaine Darwin, Diana Diamond, and Ernesto Mujico as Members-at-Large. In addition, Usha Tummala-Narra was elected by the board to complete the one year remaining on Frank Summers term as Member-at-Large.

While these new (and returning) board members will have our welcome and support, we are losing a number of members who have had years of service on our board, including Judie Alpert, Al Brok, Bart Magee, Dolores Morris, Marsha McCary, and Nina Thomas. It is good to know they will not go far. All of them will continue as committee members, although this loss of experience on the board will be keenly felt. I want to extend my heartfelt appreciation for their contributions to the Division. Finally, we are actually losing another important member, with Larry Zelnick stepping down from the Public Relations Committee after what must be well over ten years in various board and committee positions. Thanks to Larry, who will continue as a member of APA’s Committee on Division and APA Relations (CODAPAR).

APA Elections

One of the more important discussions we have at this meeting every year is to decide whether or not to endorse a candidate for APA President. This year we were faced with a number of candidates whom we know and have worked with over the years, and who asked to attend the board meeting to request our support. We found there were strong reasons to support two of the candidates for president and decide to endorse both. Here is the announcement, which you have probably already seen posted on our e-mail list:

The Board of Directors of the Division of Psychoanalysis has endorsed the candidacies of Douglas Haldeman and Steven Reisner for APA President. The board encourages its members to vote for both candidates as first or second choice on their ballots. (As a reminder, under the Hare System of voting, members are asked to rank order their choices.) Information about Steven Reisner can be found at reisnerforpresident.com; Doug Haldeman’s campaign information is available at http://president.drdoughaldeman.com/

Vote 10 for Division 39

You will be hearing about the above endorsement again when our board members call each of you in a few months requesting your support in the APA apportionment ballot. We very much want your renewed support in our “Vote 10” campaign and we certainly want to win back our 7^th Council seat that we barely lost last year. Although we often are not able to talk to you personally, we on the board very much want not only your support but also your feedback about the Division, its programs and services. If we don’t get to talk to you, please write to let us know how we are doing.

Progress on the Fund for Psychoanalysis

Marsha McCary has been spearheading an important initiative for the Division for over a year: the Fund for Psychoanalysis. She reported that we collected a significant amount of money during our Spring Meeting, our first experience with a fund drive in our history. The Fund has collected in pledges or cash over $88,000. In order to get the Fund operating, we need to have $100,000; and so the board voted to contribute $12,500 to “top out” the Fund.

What this means is that we can now proceed to form a committee that will oversee not only future fundraising but also develop a board to disburse grants from the Fund to support psychoanalytic psychology. As an aside, Marsha reports that in several meetings with APA staff and members over the weekend, the Division was recognized for its success in getting this project off the ground and running fewer than 16 months after its inception. Many other Divisions still struggle to get their funds past the $100,000 “hump” that allows them to actually get started providing grants. Although many have contributed to its success, it has been Marsha’s tireless effort that has gotten us this far. We are already planning another more ambitious fundraiser at the Spring Meeting in Santa Fe, so bring your checkbook!

Support for Early Career Professionals (ECPs)

During the debate last year on the proposed bylaws changes, one of the arguments advanced by those supporting the change was the difficulty many members, especially early career members, face in joining APA. At the Spring Meeting, Jonathan Slavin introduced a number of measures designed to help shore up Division funds and support psychologist’s continued membership in APA. I formed a task force to address these ideas, with Jaine Darwin as chair and Jonathan and Johanna Malone as members. At this meeting, a number of proposals were introduced with the goal of 1) increasing fees for Life Status members, 2) decreasing fees for ECPs attending the Spring Meeting, 3) increased information, support and encouragement for graduate students and ECPs to belong to APA, and 4) establishing a mechanism to provide rebates to ECP members who join APA.

To a great extent, the ideas and proposals developed by the task force have been overtaken by events at the APA level. As it turns out, APA is proposing to its members that APA raise the age when a member may claim Life Member status. In addition, APA has “evened out” the graduated membership fees to ECPs, resulting in a reduction in fees for many ECPs. As a result there will be a need to await the result of the APA bylaws change before changing our Life Member publications fees (our only means of increasing charges to our Life Members, unless we do away with Life Member status altogether, a change that would be possible but certainly feel like a “take away” from our senior members). If the APA bylaws pass, it will be our APA membership that has decided to limit Life Member status to those 69 or older.

The board did agree to reduce ECP fees for attendance at the Spring Meeting. They will now be the same as Graduate Student fees. We agreed that the president will charge the Graduate Student and ECP Committees to develop improved ways to encourage APA membership. The proposal to provide a mechanism for a rebate on APA dues was not supported, however, partly for the reasons described above.

In addition, there was a general consensus that our efforts should go in to finding ways to support ECP attendance at our Spring Meetings. While dissemination of cheaper accommodations, scholarships and other ways to reduce costs are important, one vital way to enhance ECP attendance is to have ECPs represented on panels and discussions, as well as on our board and committees. The ECP Committee has started a mentorship campaign to assist ECPs in writing proposals for the Spring Meeting, which should help increase presence of ECPs on panels. Although we currently have good representation of ECPs on our committees, they continue to fail to win election to the board, despite the fact that many recent candidates had served for years on Division committees. I have asked the Nominations and Elections Committee if we can look at having a separate slate for ECP (and other diversity candidates) with (or preferably without) a bylaws change.

Membership

The news here is short and sweet. Our membership numbers are up, way up, and over 3,000 for the first time in a few years. One caveat to this is that this may be the result of better numbers from APA, as Ruth Helein and Marsha McCary have done yeoman’s service in prodding loose from APA the various ways it accounts (or does not account) for our members. Still we can savor the relatively good news.

Also good news is that one new member of the Membership Committee, Cristiano Santostefano, developed a membership survey that should be in operation in the next month or so. The first survey is an “exit” survey, seeking to learn why some members have failed to renew (and hoping they simply forgot and the survey will serve as a reminder). Once in place, this should give us a way to regularly poll various constituencies of the Division to improve our services and members benefits and to develop a better database of member interests and willingness to work on various committees and projects.

While on the subject, there is an error in the current membership brochure that members should note. In revising the old membership brochure to be sure to include the rebate of Division dues to members joining through APA, somewhere along the way International Affiliates inadvertently were lumped in with Affiliates. While the information on the web site is now correct and the International Affiliates fee is $65, our recent brochure states the charge is $95. Of course anyone who is eligible to join as a Member may do so and pay the full freight, even someone outside the country. This particularly includes our Canadian members who are eligible for full privileges.

Accreditation Council for Psychoanalytic Education (ACPE)

The board had another discussion of ACPE and its budget and progress. Concerning its progress, ACPE continues to accredit psychoanalytic institutes across the country and continues to do so without charge. There has been significant progress since the Spring Meeting in that a number of institutes are now “in the pipeline” applying for accreditation. Since the primary goal of ACPE, however, is to have its standards and procedures recognized by the Department of Education, there is no indication that this will happen within the timeframe set up by ACPE, that is, by the end of this year or soon thereafter. There appear to be increasing bureaucratic roadblocks that may or may not be overcome in time.

The ACPE budget situation is clearer. Our board, along with the three other psychoanalytic organizations that make up the Psychoanalytic Consortium (Academy of Psychoanalysis and Dynamic Psychiatry, American Association for Psychoanalysis in Clinical Social Work, and American Psychoanalytic Association), have provided $100,000 payable over 18 months. The Division has contributed $20,000 for 2011 and is obligated to pay the remaining $20,000 in 2012. (Incidentally, the assessment of $40,000 for the Division is based upon our membership numbers, since the Division and the American Psychoanalytic have many more members than the other two groups.) The ACPE budget for 2013 and beyond anticipates two things: 1) ACPE is recognized by the Department of Education as an accrediting body, and 2) institutes applying for accreditation will pay for this service. As a result, there is no anticipation that ACPE will ask the Psychoanalytic Consortium for more funds (although they may ask our members or institutes graduates to donate funds).

What happens if ACPE fails to gain recognition from the government? I don’t know. It could cease or suspend operations and return unspent funds to the Consortium groups. It could carry on as an accrediting body and begin to charge for its services. Since ACPE is autonomous, its decisions will be based on whether it can survive financially and still provide a service to psychoanalysis.

One of the important questions raised during our discussion was the possible benefit of ACPE to our members. The Division has supported the ACPE process for many years and has contributed regularly to keep it in operation. The documents that make up the ACPE standards were largely the result of Division 39 members of the Consortium and it is fair to say that the Division has taken the lead in forging consensus on the Consortium. So in many ways our continued support for ACPE is the result of many years of decisions by our board.

The question of benefit to our members, as opposed to our philosophical commitment, remains important. After all, most of our members are not institute graduates; many of our members are even opposed to the regulation of psychoanalysis implied in institute training and certainly in having government oversight. At the same time, ACPE, if it succeeds, will establish psychoanalysis as a mental health discipline that has clear standards and empirical and institutional support that should benefit all of our members who work from a psychoanalytic perspective, regardless of whether they call themselves psychoanalysts or not. This should help us in defining psychoanalysis to our state legislators who have not have national standards to rely upon in determining whether or not to license psychoanalysis as a separate discipline. It should also help define psychoanalysis as a treatment that typically requires length of time and frequency of contact for optimal benefit against the accusations, frequently advanced, that anything other than super short term treatments are unnecessary, if not unethical.

APA Task Force on Clinical Treatment Guidelines

Last year APA established this task force and many of us, especially Mary Beth Cresci, worked long hours finding nominees for this group and lobbying the Practice Directorate to accept one or more of these nominees, all in the space of a month or so. I think it is a fair characterization to note that when the Practice Directorate wants our help, they are quick to call, but when we ask to be included, suddenly we are small fry indeed. In any event, none of our nominees were selected and the only practitioner selected was Jeffrey Magnavita (and for that we are quite grateful).

Lest we rest upon our indignation, some facts, however unpleasant, need to be considered. It is certainly true that our members and, I suspect, most practicing psychotherapists across the theoretical spectrum, find the idea of specific guidelines for specific disorders to be ill conceived, if not ludicrous. It is not only psychoanalysts who recognize that the person in distress is not an Anxiety Disorder or a Bipolar Disorder, but also someone whose life and being must be addressed in order to alleviate emotional trouble. Knowing this, however, does not stop the juggernaut of managed care and insurance companies who are only too eager to supply their own guidelines. And psychiatry and Big Pharma are only too glad to add their idea that psychotherapy, if needed at all, should only address medication compliance. So our practitioner colleagues, for good or ill, support the idea of having some sort of weapon to defend against assaults on their practice.

The second major issue to keep in mind is that this task force is not charged with writing guidelines but with developing guidelines for the guidelines. Before MEGO sets in just keep in mind that any guidelines will be a long time in coming and there will be ample time for our members to comment and object to the specifics. While the bureaucracy of APA can feel stifling at times, it does mean that the guidelines that result will be sufficiently general as to accommodate psychoanalytic and other forms of treatment. Who knows? Perhaps by then APA will have come to recognize that psychoanalysis is as evidence based and empirically valid (or whatever new phrase comes along in the meantime) as CBT, EFT, or LSMFT.

CODAPAR Grants

Time for another lesson learned about APA: CODAPAR is an acronym for Committee on Division and APA Relations. This group has limited funds to support interdivisional grants that typically initiate some sort of change process in APA policy or governance. This year Shara Sand, co-chair of Sexualities and Gender Identities Committee helped spearhead a grant, with Division 44 and other sponsoring Divisions to form a task force on treatment of transgendered individuals. This is an important way for our Division to build up areas of trust and collaboration with other Divisions. The group was awarded $6650 to complete its task in 2014

Committee on International Relations in Psychoanalytic Psychology (CIRPP)

Marilyn Jacobs requested and the board approved forming a new standing committee that will have as its mission increase in international presence at our Spring Meetings, in our publications and in our membership, as well as liaison with APA’s Committee on International Relations in Psychology. This committee has also applied for a CODAPAR grant in collaboration with Division 45 (Ethnic Minority Issues) and Division 52 (International Psychology) to address need for increased diversity within psychoanalysis.

New Committee Chairs and Members

The following members have been appointed (or will be appointed for 2012) to various committees:

• Membership: We have a new co-chair, Johanna Malone and new members, Daphny Ainslie, Cristiano Santostefano, Anthony Tasso.
• Nominations and Elections: Nancy McWilliams and Tamara McClintock Greenberg are reappointed for another year with Mary Beth Cresci continuing as chair.
• Awards: Mary-Joan Gerson is the new chair. Jill Bresler, David Lichtenstein and Elliot Jurist are new members. Thanks to Maureen who will serve as a member for one more year.
• Candidate: Ricardo Rieppi is the new co-chair of this committee.
• Continuing Education: Colin Ennis is the new chair for this Committee; thanks to Laura Porter who will remain on the committee to assist Colin during this transition.
• Early Career Professional: Heather-Ayn Indelicato is the new co-chair with thanks to Winnie Eng who will remain a member. Joining the committee is Daphny Ainslie, Colin Ennis. Karen Dias, Corry Gerritson, and Almas Merchant.
• Education and Training: Almas Merchant and Emily Jones are new student members.
• Graduate Students: Jonathan and Tanya Cotler are stepping down from this committee. New Co-chair is Brian Brown. New members are Emily Loscalzo and Jenna Rosen.
• Public Relations: Ankhesenamun Ball is the new co-chair; Joseph Reynoso is a new member. Larry Zelnick is stepping down.
• Research: Sherwood Waldron is the new chair, with Diana Diamond, Bill Gottdiener (Liaison, Section VI), Jim Hansell. Peter Haugen (ECP), Johanna Malone (Student), Cheri Marmoresh, Karl Stukenberg and Paul Wachtel
• Sexualities and Gender Identities: Shara Sand is the new co-chair. Scott Maguire is stepping down. New members are Brian Brown (Student), Karen Dias, and Rhonda Factor.
• International Relations: Marilyn Jacobs and Ken Reich co-chair, with Neil Altman, Richard Ruth, Marilyn Metzl, Rukhsana M. Chaudhry, Jenny Heller, Anurag Mishra, and Andrew Samuels.

Conclusion

That’s about it for a summary of our meeting. The Council Representatives will provide you with a more detailed report on the working of APA Council at the Convention. I will take a few more minutes of your time to describe a panel I attended at the Convention. It was the scheduled for 12 Noon on Sunday, not a “prime time” for sessions, but before the session began the room was packed with numerous standees. The panel was chaired by Jeffrey Magnavita and the presenters were Lorna Benjamin, Laura Brown and Nancy McWilliams, with a discussion by Nadine Kaslow. The presenters’ task was to show a short video clip of clinical work and to discuss their theoretical and clinical assumptions that guide their work, especially in reference to the video vignette.

As a “plug,” this was the first opportunity to view even a small part of the video that APA has recently published with Nancy McWilliams, Les Greenberg and Judith Beck interviewing two separate clients over two sessions. (Shorthand description: The “Gloria” tapes redone, this time with a psychoanalyst) And Nancy’s video clip was a vivid demonstration of both empathy and critical distance in allowing the client to express and experience walled-off grief over his father’s death. I highly recommend the videos: Three Approaches to Psychotherapy With a Female Client and its companion, Three Approaches to Psychotherapy With a Male Client.

But back to the panel. I found my self impressed overall with the work presented and the coherence of their theoretical approach and rationale for the interventions offered. I could but choose not to resist that the theoretical stances offered were largely completely compatible with psychoanalytic perspective. Jeffrey Magnavita emphasized the intergenerational transmission of abuse in working with a woman concerned about being too hard on her child only to “open up” to explore her own history of abuse. Lorna Benjamin emphasized the “positive” side of self-destructive behavior and the need for clients to understand that their seemingly irrational actions were in one sense a “gift of love” to a parent who both abused and in some ways seduced the child, so that reaching out to new and healthy relationships and patterns of behaving are actually threatening. Laura Brown addressed the issue of empowerment, and how women fail to recognize and claim their own power, and this in working with a client who explicitly disclaimed any interest in being powerful and instead wanted the therapist to “tell her what to do.”

As I partly described above, Nancy’s client gradually began to link his increased anxiety over the past months with concerns about his daughter’s immanent departure for college. This in turn allowed him to explore the impact of his father’s death when he was just a boy and how walled off he has been from his feelings all his life. Finally, Nancy made an observation that his “caretaking” and need to please as a way of warding off pain extended into the session and his readiness to help her feel like the “good therapist.” During his short emotional breakdown as his felt the grief of his father’s loss, Nancy sat more or less in attentive silence and ended with a construction of the events during the session that paid attention not only to his evident pain, but also his characterological stance (and strength) of transforming pain into reflection and intellectualization.

So here is my point, obviously a biased one, but with each of the other therapists I felt the heavy hand of theory guiding and directing the clients in far more overt ways than I saw in Nancy’s work. It seemed to me that each had a clear (and certainly useful) lens through which they saw the client. My conclusion is that in some ways good psychoanalytic therapy is actually less theory-driven, less focused on tying up loose ends, than the other approaches I observed. All the presenters offered up a version of themselves, in their theory, in their openness to the clients, and in their understanding of change and health. All of these attributes, the attributes of good therapy, are obscured by the tiresome battle of “evidence based” treatments and the hoops various therapists go through to demonstrate that their work is scientific. I am pleased that Jeffrey Magnavita is on the APA Task Force for Treatment Guidelines, but I despair for our field until and unless research meets clinical practice (and vice-versa) to have a real conversation about how to help real patients with real problems.

And Beyond

I want to read your comments and suggestions. I very much want you to attend our next meeting in Santa Fe. Register early and often for excellent savings and come to Santa Fe to participate not only in learning but in discussing our craft, our future, and our need for connection.

Psychiatry and Big Pharma: Waiting for the Perp Walk to Begin

Much heat has been expended debating the relative merits of psychoanalytic work versus other approaches, especially CBT. While research and theory is of undoubted importance in better defining quality and success in psychotherapy, the more enduring threat to independent practice of psychoanalysis and psychoanalytic psychotherapy does not come from CBT practitioners, or even CBT researchers, however dearly we may resent their current hegemony in academia. I submit it that any successful practicing clinician, regardless of orientation, works with resistance, transference, unconscious processes, dissociated affect, repressed memories, as well as habits, symptoms, cognitive distortions and so on, regardless of what labels describe these concepts. Working psychotherapists often have far more in common in their understanding and approach than research would suggest.

For the average clinician struggling to survive financially in the marketplace, the issues they face are quite different than deciding the relative efficacy of EFPP, DBT, EMDR, LTPP or any of the many “brands” of psychotherapy. The first barrier for all psychotherapists is the o’erweening influence of Big Pharma promoting the unthinking assumption on the part of the general public that emotional problems are best treated with medications. The second barrier is the pernicious ascendance of managed care restrictions on treatment with its wholesale insistence on defining mental health as a service treating only the “severely mentally ill” with medications and, perhaps, ultra short-term therapy.  The result of this emphasis has been to provide incentives to overpathologize our patients (to obtain reimbursements) and to underplay our commitment to meaning and truth in working with our patients (to appear compliant with reviewers). The false assumption that CBT treatment is super-fast provides the cover for managed care to continually ratchet down care and results in a false competition among psychotherapists in a perverse version of “Name that Tune:” “I can treat that person in three sessions!”

These two obstacles to psychotherapy practice have a common root in the decision of the psychiatric profession to become “respectable” (and prosperous) by insisting that all psychological and emotional ills are merely manifestations of physical disorders, brain malfunction, misfiring neurotransmitters, etc., that can be treated scientifically without recourse to such ephemera as the patient’s life struggles, his failed social support systems, her resilience and motivation to change, and so on. The manifest failure of psychiatry to succeed in this endeavor to become a “real” science of brain disorders has had little or no impact on its undoubted success in transforming mental health treatment into drug treatment as first, last and only approach.

It was not always thus. It is not so very long ago psychiatry and psychiatric diagnosis was under withering attack by many, from Thomas Szasz, to R.D. Laing, to Michel Foucault, who from varying perspectives condemned psychiatric diagnosis as nothing more than either moralizing about behaviors we disliked, labeling nonconforming individuals as “sick” (rather than annoying), or injecting the power of the state to regulate intimate and personal aspects of our lives, and so on. In movies (King of Hearts), novels (One Flew Over the Cuckoo’s Nest) and Broadway musicals (Anyone Can Whistle), the notion that there was any significant difference between the sane and the insane was pilloried. Perhaps the high water mark was the decision of the American Psychiatric Association in 1974 to strike out homosexuality as a mental illness. For the first time, an established mental illness was voted out of existence! Who knew such a thing could happen?  But whatever happened, it did not last long and soon psychiatry was riding high, higher than ever before.

Psychiatry’s success came about through its alliance with a pharmaceutical industry ever eager to expand the use of its drugs in treating as wide a variety of illnesses as possible. Drugs developed to treat physical illness proved remarkably adaptable in addressing psychiatric ills. With the development of the DSM, especially its recent incarnations, psychiatry was able to gain a monopoly over diagnosis of mental problems, insulating itself from the rising tide of other mental health professions that emerged in the 60s and 70s, imposing upon those professions a concept of mental health and illness that was alien to their traditions (however eager they were to use the DSM to obtain insurance reimbursement!). The date of introduction of Prozac (1987) is perhaps the best marker for the consolidating alliance with Big Pharma. This was also a boon to managed care as it developed, allowing insurance companies to play the two-pronged game of sequestering off mental health care as “behavioral treatment” but rarely paying unless treatment included medication as well for a presumed brain disorder.

So maybe Pogo was wrong and there really is an enemy other than “us” that has been able to convince the public, policymakers and the great mass of physicians that emotional difficulties, drug addiction, marital conflicts, etc., are nothing more that examples of “drug deficiency” easily enough treated with the right kind and combination of medications. The fact that psychotherapy works, that psychotherapy not only addresses symptoms but also provides for increased quality of living, has been obscured by the successful alliance of psychiatry with the pharmaceutical industry. The fact that the so-called brain disorders remain undiscovered has not flagged both the researchers and the public’s enthusiasm for the “next big thing.”

While waiting for the day when the incestuous relationship between professional psychiatry and the pharmaceutical industry finally stirs the legal system to substantive action, we can take solace in the recent revelations that Harvard University[1] has imposed sanctions on the eminent child psychiatrist Joseph Biederman and two colleagues. As reported in the Boston Globe[2], the three psychiatrists admitted to unspecified violations of institutional policies and are barred from receiving remuneration for any industry-sponsored activity for one year and will remain “under review” for another two years. Although Biederman’s links to Big Pharma have been know for years and prompted a public dressing-down before a congressional committee in 2008 by Sen. Charles Grassley, this is the most significant consequence he has had to endure to date.

This revelation was particularly gratifying to me because I had suffered three days of indoctrination at a Harvard workshop years ago on the benefits of drug treatment for children and adolescents. In addition to such compelling encouragement offered by Dr. Biederman to simply ignore the “black box” warnings on use of stimulants and antidepressants, there was an appalling paucity of thoughtfulness throughout the sessions. Speakers referred almost solely to the symptom lists offered by the DSM-IV in determining diagnoses, sadly shaking their heads at times as they noted the alarming rise of psychiatric illness among children and adolescents, and asking for our commiseration with their “discovery” of an equally astonishing rise in comorbidity. Every speaker described drugs as the main form of treatment with occasional nods to CBT and “family work” as having some benefit. The speaker discussing eating disorders ruefully noted that neither drugs nor CBT have been found effective in treating anorexia and bulimia and that long-term psychoanalytic psychotherapy, while effective, was not offered due to limitations imposed by managed care.

The fact that researchers at one of the most prestigious university and teaching hospital in the country would spout such unrelieved nonsense was profoundly depressing. My discovery that many of these same researchers had their hands in the till of the pharmaceutical industry to the tune of million of dollars came later; and I have patiently waited for these revelations to merit more than New York Times editorials and congressional scoldings. I have eagerly hoped that the “perp walk” would begin and fervently desired that Dr. Biederman would be among the first. Imagine my dismay that the actions that have been taken in this case is that he and his colleagues have gotten little more than a wrist slap, with their institution rallying round them and intoning piously that violations of conflict-of-interest rules will henceforth be strictly enforced . . in the future.[3]

There has been a lot of information out there in the last ten years or so concerning the absolute corrupting relationship between organized psychiatry and Big Pharma. It is commonplace to observe that universities want to keep psychiatric researchers happy; drug companies want successful outcomes for their research trials, and pharmaceutical representatives would be happy to announce that Prozac (or Abilify, or Seroquel) have also been found to cure Asperger’s, Alzheimer’s or Alcoholism on the basis of solid anecdotal evidence. And in may ways it is hardly surprising that institutions tend to rally round their own in the face of criticism, and money talks and power corrupts, and on and on. What has been less well publicized is the utter vacuity of thought within psychiatry to the point that the bizarre notion of “chemical imbalance” as cause for depression (and everything else) and the prospect that almost everyone suffers from some sort of mental illness has become a substitute for any reasoned exploration of what ails our patients and ourselves. Public credulity has been a reliable ally in the promotion of one psychiatric syndrome into prominence for a few years before giving place to the “next new thing,” such that ADHD is far less fashionable to have than the newly minted Asperger’s Syndrome. And it is de rigueur for bipolar disorders to have just a little psychotic disorder on the side.

In a series of articles recently published in the New York Review of Books, Marcia Angell reviews the state of mental illness in this country and the overwhelming involvement of the pharmaceutical industry allied with psychiatry to discover ever-new forms of mental illness in conjunction with ever-new drug treatments. In the first article[4] she describes the astonishing rise in diagnosis of mental illness over the last twenty years and links this increase to the widespread availability of medications designed to treat these problems beginning 50 years ago with the introduction of Thorazine, but taking off 30 years ago as “new” antidepressants, anti-psychotics and so on, came on the market. Drugs that were found to partially alleviate symptoms of depression and psychosis have led to the largely unquestioned assertion that drugs that affect serotonin and dopamine levels in the brain are only correcting a “chemical imbalance” that was the cause of the disorder in the first place, although by this logic headaches are caused by aspirin deficiency!

She reviews the work of Irving Kirsch[5] in detailing the failure of researchers to find the elusive “chemical imbalance” after many attempts and the increasing discovery that the effects of antidepressant medication are largely due to placebo effects. This remarkable discovery has been increasingly replicated in double blind studies. These studies have found that the beneficial effects of antidepressant medication, while statistically significant, are not clinically any better than those achieved by use of placebos. Moreover, when the placebo used in drug research mimics the same side effects of antidepressants, the differences in effectiveness trend toward zero.

While one possible implication of these studies is a kind of “no harm, no foul” outcome (after all, if patients report improvements, what’s the problem?), Robert Whitaker explores the darker side of the use of psychoactive medications. In Anatomy of an Illness[6], Whitaker notes that the long-term use of these medications does have significant, long-term and deleterious effects, including shrinkage of the prefrontal cortex, an area of the brain that we would sort of like to retain for as long as possible. While psychiatric science has failed to find the chemical imbalance that causes mental illness, Whitaker points out that psychoactive drugs to indeed cause “chemical imbalance” as the body tries to adjust to these medications, sometimes to three or four medications, each one “chasing” the side effects of the others. So, the diagnosis of Attention Deficit Hyperactivity Disorder gives way in time to the emergence of Bipolar Disorder with solemn assurance that it was “there” all along, without any consideration that stimulants impact sleep (especially when used “as needed”) and that disturbed sleep tends to lead to depression and anger, merging imperceptibly into bipolar illness..

In the second article[7], Angell focuses on the development of the DSM in it’s various iterations and the ongoing revision that threatens to vastly increase the number of psychiatric conditions available, expanding the reach of diagnoses to include such categories as “psychotic risk syndrome,” and with a range of “spectrum” disorders to allow diagnosis below the threshold of actual symptoms. Children may be discovered to have “temper dysregulation disorder” in the new DSM-V, presumably allowing all children to be found to suffer from mental illness.

Angell addresses the perverse incentive parents, especially poor parents, face when financial benefits flow from having a child with a mental illness and therefore eligible to receive SSI benefits, including Medicaid. Curiously, she does not address the perquisites of diagnosis that benefit the middle and upper classes, so that a child with ADHD may be assured to “accommodations” well into college and beyond. Additionally, she does not address the financial benefits to psychiatrists in being able to diagnose, and be reimbursed for, an expanding list of new disorders. After all, the DSM was originally developed as a way for psychiatrists to justify insurance reimbursement and the success of the first DSM has not been lost on generations of psychiatrists. Daniel Carlat[8] exemplifies the psychiatric profession, with its own perverse incentives to see patients for 15-20 minutes, prescribing solely on the basis of symptoms and reported symptom relief, all of which allows him to make at least twice as much as a psychotherapist.

Angell comes to a final conclusion,

The books by Irving Kirsch, Robert Whitaker and Daniel Carlat are powerful indictments of the way psychiatry is now practiced . . At the very least, we need to stop thinking of psychoactive drugs as the best, and often the only, treatment for mental illness or emotional distress. Both psychotherapy and exercise have been shown to be as effective as drugs for depression, and their effects are longer lasting, but unfortunately, there is no industry to push these alternatives and Americans have come to believe that pills must be more potent.

Her conclusions seem woefully incomplete and there is a great deal more to be said about those treatments and interventions, including psychoanalytic psychotherapy, that work and have sustained and enduring benefits. While this was not the purpose of her review, it remains an important task for us all educate the public. For at least the last 30 years, the pharmaceutical industry has been on an unremitting and largely successful campaign to convince Americans that their depression, anxiety, blue moods, and shyness are illnesses that can be alleviated with a simple pill. The realities that Angell reviews (and Kirsch and Whitaker have documented), will not have any impact on the public without a sustained campaign to educate Americans to the shortcomings and dangers of drug treatments and the benefits of alternatives.

We can and must do better to address this unholy alliance of psychiatry, Big Pharma, and managed care. It is not sufficient that we know that drug treatment for emotional problems, however useful in the short term, does not address the underlying problems of living that our patients struggle with. The reality is that drug companies and the insurance industry have far greater clout with policymakers and far greater resources to indoctrinate the public (and truth be told, Americans have always sought the “quick fix” in many areas) than any of our organizations. Even combined we cannot compete on a level playing field; but we can begin to address what is essentially an illusion that medication cures emotional distress and that psychotherapy in whatever iteration is essentially an adjunctive approach to ensure patient compliance with medications.

One of the goals of Division 39 has been for our Council Representatives to forge closer connections with the other practice divisions and our new Committee for Professional Affairs will also have collaboration with the Practice Directorate as well as the practice divisions as a major goal.  Finally, the Psychoanalytic Consortium has agreed to address the issue of public relations for psychoanalysis and psychoanalytic psychotherapy at every meeting. Psychotherapists of whatever orientation need to stand together to protect a patient’s right to choice, privacy, access, and quality in mental health and substance abuse care. Make you voice heard within Division 39 and APA by attending the APA Annual Convention in August and learning more about ways to promote and protect psychoanalytic psychology as theory, research paradigm and, especially, treatment.

                       
 
                        

---

[1] This newspaper article came to me from Kenneth S. Pope’s e-mail list kspope.com. Thanks to Ken Pope for distributing such a wide range of information relevant to psychology and psychotherapy.

[2] http://articles.boston.com/2011-07-02/lifestyle/29731040_1_harvard-doctors-harvard-medical-school-physicians

[3] In fairness, psychiatry is not alone in being in bed with Big Pharma and, as documented by the investigative organization, Pro Publica, universities have routinely failed to enforce their own conflict of interest policies and have only been goaded into doing so by investigations such as Pro Publica’s. See http://www.propublica.org/article/medical-schools-plug-holes-in-conflict-of-interest-policies and thanks again to Ken Pope for bringing this to our attention.

[4] Marcia, A (June 23, 2011). The epidemic of mental illness, New York review of books, available online at http://www.nybooks.com/articles/archives/2011/jun/23/epidemic-mental-illness-why/?pagination=false

[5] Kirsch, I. (2010). The emperor’s new drugs: Exploding the antidepressant myth, New York: Basic Books.

[6] Whitaker, R. (2010). Anatomy of an epidemic: Magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America, New York: Crown.

[7] and Marcia, A. (July 14, 2011). The illusions of psychiatry, New York Review of Books, available at http://www.nybooks.com/articles/archives/2011/jul/14/illusions-of-psychiatry/

[8] Carlat, D. (2011). Unhinged: The trouble with psychiatry—A doctor’s revelations about a profession in crisis, New York: Free Press.